Healthcare Provider Details

I. General information

NPI: 1083654016
Provider Name (Legal Business Name): MMPS OGDEN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 02/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1485 E SKYLINE DR
OGDEN UT
84405-4837
US

IV. Provider business mailing address

1485 E SKYLINE DR
OGDEN UT
84405-4837
US

V. Phone/Fax

Practice location:
  • Phone: 801-475-4552
  • Fax: 801-475-4578
Mailing address:
  • Phone: 801-475-4552
  • Fax: 801-475-4578

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number5032435-0160
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number5032435-0160
License Number StateUT

VIII. Authorized Official

Name: MRS. JULIE PENROD
Title or Position: CEO
Credential: CEO
Phone: 801-284-1705